Thoracic/back

Rapid Review

• Differentials
  • “CRAFTI”
    • Compression
      • Cauda equina
      • Conus medullaris
      • Epidural hematoma
    • Renal stone 
    • Aortic aneurysm/dissection
    • Fracture
    • Tumor
    • Infection/Inflammatory
      • Pyelonephritis
      • Perinephric abscess
      • Epidural abscess
      • Osteomyelitis
      • Discitis
      • Transverse myelitis
  • Other common causes
    • Mechanical low back pain
    • Sciatica/Radiculopathy
• History
  • Recent injury
    • Consider fracture, strain
  • Recent unintentional weight loss
    • Consider malignancy
  • IV drug use
    • Consider epidural abscess
  • Syncopal episode
    • Consider aortic dissection, aneurysm
  • Urinary incontinence or saddle anesthesia
    • Consider cauda equina
  • Fever/chills
    • Consider infectious process
• Physical Exam
  • Spinal tenderness. Step-off deformity.
    • Consider fracture
  • CVA tenderness
    • Consider nephrolithiasis or pyelonephritis
  • Sphincter dysfunction
    • Consider cauda equina
• Work-Up
  • Labs
    • CBC, BMP, ESR, CRP
    • Urinalysis
    • Beta-hCG
    • Post-Void Residual
  • Imaging
    • X-ray (spinal)
    • CT Spine (non-contrast)

Pearls

Deep Dive

• Back Pain (EMRA)

Rapid Review

• Differentials
  • Cardiovascular
    • Acute coronary syndrome
    • Aortic dissection
    • Pericarditis
  • Pulmonary
    • Pulmonary embolism
    • Pneumothorax
    • Pneumonia
  • Gastrointestinal
    • Boerhaave’s Syndrome
    • Pneumomediastinum
    • Gastroesophageal Reflux (GERD)
  • Thoracic Wall
    • Costochondritis
    • Rib contusion/fracture
    • Shingles
  • Psychiatric
    • Anxiety/Panic attack
• History
  • Ripping/tearing pain
    • Consider aortic dissection
  • Exertional
    • Consider ACS, heart failure
  • Pleuritic
    • Consider PE, pericarditis, pneumonia
  • Positional
    • Consider pericarditis or myocarditis
  • Estrogen use
    • Consider PE
  • Hx of HTN, HLD, DM, or PVD
    • Consider ACS
  • Prior cardiac procedures (stents, bypass, echo, catheterization, etc.)
    • Consider ACS or surgical complications
  • History of anxiety
    • Consider panic attack
  • Fever/Chills
    • Consider pneumonia or other infectious causes
• Physical Exam
  • JVD
    • Suggests right-sided HF
  • New murmurs
    • Consider valvular dysfunction
  • Abnormal lung sounds (rales, rhonchi, wheezing)
    • Consider pneumonia, CHF exacerbation, etc.
  • Chest wall tenderness
    • Consider costochondritis, pericarditis
  • Edema
    • Consider heart failure
• Work-Up
  • EKG
    • Look for bradycardia, tachycardia, ST-segment elevation/depression,
  • Labs
    • CBC, BMP
    • Troponin
    • D-Dimer
  • Imaging
    • CXR
    • CT PE (if concern for pulmonary embolism)
    • CT aortogram (if concern for aortic dissection
    • Echocardiogram (if concern for pericardial effusion)

Pearls

Deep Dive

• Chest Pain (SAEM)

Rapid Review

• Differentials
  • Arrhythmias
    • Sinus tachycardia
    • AVRT/AVnRT
    • Atrial flutter
    • Atrial fibrillation
    • Multifocal Atrial Tachycardia
    • Ventricular Tachycardia
    • PVC’s or PAC’s
  • Valvular Disease
    • Mitral or aortic insufficiency
    • Mitral valve prolapse
  • Psychiatric
    • Panic attack
    • Anxiety
    • Somatization
    • Depression
  • Drug/Medication Use
    • Caffeine
    • Amphetamines
    • Cocaine
    • Aspirin overdose
    • Alcohol/Opiate withdrawal
  • Other
    • ThyrotoxicosisAnemia
    • Addisonian Crisis
    • Carcinoid Syndrome
• History
  • Recent ingestion of substance
    • Consider caffeine, amphetamines, or alcohol
  • Recent stressors
    • Consider anxiety, depression, panic disorder
  • Associated with chest pain/SOB on exertion
    • Consider ACS, CHF, valvular disorders
• Physical Exam
  • Murmurs
    • Consider valvular dysfunction
  • JVD
    • Consider heart failure
  • Irregularly irregular heart rate
    • Consider atrial fibrillation/flutter
• Work-Up
  • EKG
  • Labs
    • CBC, BMP
    • Troponin
    • TSH + Free T4
    • Urine drug screen
    • Pregnancy test

Pearls

Deep Dive

• Palpitations (Merck Manual)

Rapid Review

• Differentials
  • Airway
    • Airway obstruction
    • Anaphylaxis
    • Abscess or tumor
  • Breathing
    • Asthma
    • Pulmonary embolism
    • COPD exacerbation
    • Pleural effusion
    • Noncardiogenic edema
    • Pneumothorax
    • Pneumonia
  • Cardiac
    • Congestive heart failure
    • Pericardial effusion/Cardiac tamponade
    • Acute Coronary Syndrome
    • Arrhythmia
    • Valvular dysfunction
  • Other
    • Anemia
    • Anxiety/Panic attack
    • Trauma (pulmonary contusion/flail chest)
    • Diabetic Ketoacidosis
    • CO poisoning
• History
  • Exertional
    • Suggests ACS, HF, or PE
  • History of previous lung disorders
    • Consider COPD, Asthma
  • Hx of diabetes
    • Consider DKA
  • History of cardiac disorders
    • Consider ACS, HF, valvular problems
  • Recent trauma
    • Consider pneumothorax, pulmonary contusion
  • Recent travel/immobilization. Estrogen use
    • Consider pulmonary embolism
  • Fever/chills
    • Consider infectious causes
• Physical Exam
  • Apparent distress or tripod positioning
    • Consider need for urgent airway/breathing management
  • Murmurs, rubs, gallops
    • Consider HF, pericarditis
  • JVD
    • Consider right-sided HF
  • Abnormal lung sounds (rales, rhonchi, wheezing)
    • Consider HF, asthma, COPD, pneumonia
• Work-Up
  • EKG
  • Labs
    • CBC, BMP, troponin, d-dimer, BNP
  • Imaging
    • CT PE (if considering pulmonary embolism)
    • Echo (if suspect effusion, HF)

Pearls

Deep Dive

• Respiratory Distress: An emergency medicine approach (First 10 EM)